Download - Pneumonia in Adults.2013
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How Do I Think AboutPneumonia?
Resident’s Thursday School
07!"!0#$
% Rush Pierce %r& 'D& 'PH
Di(ision o) Hos*ital 'edicine&+,'
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-utline
• Re(iew resources
• .ase based discussion that will
co(er – Dia/nosis
– Treatment
• ased on – IDSAATS .AP 1!0072 /uidelines
– H.AP3APHAP 1!00"2 /uidelinesHow Do I Think About Pneumonia?07!"!0#$ !
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Resources
• 4uidelines a(ailable
– +,'H site 1htt*s5hos*itals6health6unm6eduintranetInde6c)m 2
– IDSA website 8 /uidelines a(ailable )or download toPalm or iPhone 1htt*5www6idsociety6or/.ontent6as*?id9:0;; 2
• +*
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07!"!0#$ >How Do I Think About Pneumonia?
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.ase #
• " yo male smoker has ! days o) chills&dys*nea& and *urulent s*utum6 He has no risk)actors )or HI3& donates blood $year 1mostrecently one month a/o2 and does not take any
medications6 T 9 $;6#& P 9 ##00& HR 9 :"&RR 9 !0& Sa-! 9 ;:@ RA6 amination showsno abnormalities6 .BR is read as Cminimalstreakin/ at lun/ bases& atelectasis (s6 early
*neumonia• Should I treat with antibiotics?
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Does this *atient ha(e*neumonia?
• H5
• P5 3S most use)ul in *redictin/ se(erity• .BR is /old standard < may be normal in u*
to 7@ on admissionE assume *neumonia*resent i) con(incin/ h and )ocal P
• Sus*ected *neumonia with ne/ .BR 8consider )u .BR or .T 1more sensiti(e2
How Do I Think About Pneumonia?07!"!0#$ 7
Sensitivity Specifcity
Fe(erchills ;"@
Dys*nea 70@
Purulents*utum
"0@
Any o) abo(e 70 8 :0@ >0 8 "0@
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Thinkin/ about *neumonia5 >ste*s
#6 Put into initial clinical classiGcation
!6 Decide site o) care$6 Tests )or etiolo/y
>6 Initial em*iric thera*y
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Ste* #5Initial clinical classiGcation
#6 'aor immunodeGciency
!6 Tuberculosis 1sus*ected or established2
$6 Relati(ely normal hosts without T1location at time o) in)ection2
• .ommunity
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.ase !
• "" yo homeless man )rom 'eico has !days o) chills& ni/ht sweats& dys*nea& and*urulent s*utum without hemo*tysis6 He
has not lost wei/ht6 He has no risk)actors )or HI3& takes no medications& andis not diabetic6 am re(eals T 9 $;6#& P9 ##00& HR 9 :"& RR 9 !0& Sa-! 9
;:@ RA& crackles at the ri/ht base6
• Should I order airborne isolation?
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07!"!0#$ ##How Do I Think About Pneumonia?
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hen to sus*ect T1Intern Sur(i(al 4uide2
• I) two or more ss
– Hemo*tysis
– .ou/h J ! weeks
– ,i/ht sweats
– t loss J #0 K in $ mos
• I) sus*icious .BR 1anyo) these2
– +**er lobe inGltrates
– 'iliary *attern
– .a(itary lesions
– ,odular inGltrate
Res*onse to sus*ected T
-rder airborn isolation and.BR
-rder AF smears& cultures1does not ha(e to be =A'L2
How Do I Think About Pneumonia?07!"!0#$ #!
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Ste* #5Initial clinical classiGcation
#6 'aor immunodeGciency
!6 Tuberculosis 1sus*ected or established2
$6 Relati(ely normal hosts without T1location at time o) in)ection2
• .ommunity
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.AP (s H.AP3APH.AP
• Healthcare
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.ase !
• The *atient has ne(er beenhos*italiOed& resides at home& doesnot take dialysi& has not recei(ed
chemothera*y& and his s*ouse hasnot been sick
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Ste* #5Initial clinical classiGcation
#6 'aor immunodeGciency
!6 Tuberculosis 1sus*ected or established2
$6 Relati(ely normal hosts without T1location at time o) in)ection2
• .ommunity
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Thinkin/ about *neumonia5 >ste*s
#6 Put into initial clinical classiGcation
!6 Decide site o) care$6 Tests )or etiolo/y
>6 Initial em*iric thera*y
How Do I Think About Pneumonia?07!"!0#$ #7
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.ase $
• " yo male smoker has ! days o) chills&dys*nea& N *urulent s*utum6 ,osi/niGcant P'H6 He has )elt and eaten*oorly6 T 9 $;6#& P 9 ##00& HR 9 :"&RR 9 !0& Sa-! 9 ;:@ RA& crackles at theri/ht a*e6 He is not con)used6 . 9#"& HH 9 #>6">!& ,a 9 #!;& 9 $6"& .l
9 #0"& .-! 9 !06 +,creat 9 $!#6>6.BR shows R+M inGltrate6
• .an I send this *atient home?
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www6meddean6luc6edu07!"!0#$ #:How Do I Think About Pneumonia?
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07!"!0#$ !0How Do I Think About Pneumonia?
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Pneumonia Se(erity Inde1PSI2
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.+R
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I.+ admission 9 one maor or $ minor
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Thinkin/ about *neumonia5 >ste*s
#6 Put into initial clinical classiGcation
!6 Decide site o) care$6 Tests )or etiolo/y
>6 Initial em*iric thera*y
How Do I Think About Pneumonia?07!"!0#$ !>
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.ase $ < continued
• " yo male smoker has ! days o) chills&dys*nea& N *urulent s*utum6 ,osi/niGcant P'H6 He drinks alcohole(eryday6 T 9 $;6#& P 9 ##00& HR 9 :"&RR 9 !0& Sa-! 9 ;:@ RA& crackles at theri/ht base6 He is not con)used6 . 9#"& HH 9 #>6">!& ,a 9 #!;& 9 $6"& .l
9 #0"& .-! 9 !06 +,creat 9 $!#6>6.BR shows R+M inGltrate6
• hat etiolo/ic tests do I order?
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Dia/nostic tests )or etiolo/y
• hy not etiolo/ic tests )or e(eryone?
• -ut*t 8 4et Sa-!E Routine tests )oretiolo/y are o*tional
• In*t < lood and s*utum culturesrecommended )or most 1but not all2
• I.+ < blood and s*utum cultures& andMe/ionella and *neumococcal +AT
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Thinkin/ about *neumonia5 >ste*s
#6 Put into initial clinical classiGcation
!6 Decide site o) care$6 Tests )or etiolo/y
>6 Initial em*iric thera*y
How Do I Think About Pneumonia?07!"!0#$ $0
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.ase >
• !> yo *re(iously healthy )emale has! days o) chills& dys*nea& N *urulents*utum6 ,o si/niGcant P'H6 T 9
$;6#& P 9 ##00& HR 9 :"& RR 9!0& Sa-! 9 :!@ RA& crackles at theri/ht base6 .,. and .hem 7
normal6 .BR 9 early RMM *neumonia• hat antibiotics should I order?
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m*iric R o) out*atient.AP
• Healthy and no antibiotics in *ast $ months – 'acrolide -R doycycline
• I) cardio*ulmonary dO& eta
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-ut*atient RB o) .AP
• .andidates )or out*t thera*y
– Mow PSI or .+R
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.ase $ < continued
• " yo male smoker has ! days o) chills&dys*nea& N *urulent s*utum6 ,osi/niGcant P'H6 He has )elt and eaten*oorly6 T 9 $;6#& P 9 ##00& HR 9 :"&RR 9 !0& Sa-! 9 ;:@ RA& crackles at theri/ht base6 He is not con)used6 . 9#"& HH 9 #>6">!& ,a 9 #!;& 9 $6"& .l
9 #0"& .-! 9 !06 +,creat 9 $!#6>6.BR shows R+M inGltrate
• hat antibiotics do you order?
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m*iric R o) in*atient .AP 8 nos*ecial considerations
• In*atient 8 ward5
– res*iratory =uinolone
-R
– 1ce)triaone or ce)taOidime2 1aOithro ordoy2
• I.+ 8
– 1ce)triaone or ce)taOidime2 1I3 aOithro orres*iratory =uinolone2
– I) P., aller/ic use aOtreonam res*iratory=uinolone
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m*iric in*atient R o) .AP 8s*ecial considerations
• Pseudomonas – su//esti(e /ram stain& bronchiectasis& )re= eacs o)
.-PD *rior antibiotic r
– Re/imens5
– 1osyn or mere*enam2 ci*ro-R
– 1osyn or mere*enam or aOtreonam2 amino/lycoside res*iratory =uinolone
• 'RSA
– su//esti(e /ram stain& SRD& I3D+& *rior inuenOa&*rior antibiotics es* =uinolones& or much 'RSA incommunity
– Re/imen5 Add lineOolid -R (ancomycin
How Do I Think About Pneumonia?07!"!0#$ $;
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.ase $ < continued
• " yo male ! days a/o with R+M*neumonia and treated with ce)triaoneand aOithromycin6 -n rounds is )eelin/
better& eatin/& not con)used6 T 9 $76:&HR 9 #0!& P 9 #0"7"& RR 9 #!& Sa-!9 ;;@ on room air
• hen I can I switch to an oral re/imen
and what re/imen?
• hen can the *t /o home?
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Switchin/ to oral
• I) s*eciGc *atho/en identiGed& switch tonarrow s*ectrum thera*y
• hen clinically im*ro(in/&
hemodynamically stable& able to take orals&switch to oral r 8 i) no *atho/en& o)tenaOithro alone
• Duration 9 at least " days& and until
a)ebrile )or two days& and ha(e only onesi/n o) clinical instability6 I) *atho/en isPseudomonas treat at least #> days
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Timin/ o) dischar/e
Readmission rate or death: no instability = 10%; 1 instability = 14%; 2+ instabilities = 46%
How Do I Think About Pneumonia?07!"!0#$ >!
P i b ) th
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Pneumonia 8 be)ore they /ohome
• Smokin/ cessation
• 3accination
How Do I Think About Pneumonia?07!"!0#$ >$
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.AP 8 hat’s ,ew
• Increasin/ reco/nition o) (iral *atho/ens
• .onsideration o) en(ironmentale*osures as risk )actor )or .AP
• +se o) P.R 1and other tests2 to /uideinitial antibiotic choice
• +se o) inammatory markers to hel*
with dia/nosis and /uide thera*y• 3accine eUcacy
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Vuestions?
07!"!0#$ How Do I Think About Pneumonia? >"
m* r c t era*y o
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m* r c t era*y oH.APHAP3AP with 'DR
risk )actorsce)e*ime& ce)taOadime& imi*enam& or osyn
PM+S
ci*rooacin& le(ooacin& or amino/lycoside
• I) 'RSA concerns add lineOolid or(ancomicin
How Do I Think About Pneumonia?07!"!0#$ >
S it hi t l th )
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Switchin/ to oral thera*y )orH.APHAP3AP
Pseudo: if sens
i!ro + "u#$doy$linda
&R'":
sensiti(ities
i!ro + "u#$doy$linda )R moi
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As*iration
• hen to use5 obser(edsus*ectedas*iration )e(er or leucocytosis orinGltrate
• Re/imens5
– +nasyn 1doy -R aOithro2
Au/mentin or clinda – Res*iratory =uinolone
How Do I Think About Pneumonia?07!"!0#$ >;
, di i
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,on
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.linical res*onse to non<res*ondin/ *neumonia
• Ree(aluate initial microbiolo/ic results 8 consider +AT
• Reassess risk )actors )or in)ection with unusualor/anism
• Re*eat blood cultures )or worsenin/ *neumonia orclinical deterioration
• Mook )or secondary in)ections 1catheter& urinary& skin2
• 4et .T to R- PT& thoracentesis to R- em*yema&bronchosco*y to R- unusual *atho/ens